Understanding tiptoe behaviours in autism: a multidimensional study on associated characteristics and smart socks with integrated sensor technologies for detection

Tiptoe behaviours (TTB) – walking, running and standing on tiptoes – are frequently observed in children with autism, yet their characteristics and association with core autism features and other developmental domains remain poorly understood. Moreover, quantitative accessible measurement methods are lacking. This study aimed to investigate the characteristics of TTB—including related contexts, situations, and emotional states—and to quantitatively measure their frequency and duration. It also evaluated the comfort, accuracy, sensitivity, and specificity of sensor-equipped smart socks, and examined the associations between observed TTB and motor, language, and core autism features in autistic children. To address these research questions two complementary approaches were used: an online survey completed by 82 respondents and a laboratory study involving sixteen typically developing children and eighteen children with or a working hypothesis of autism. Behavioural coding was used to quantify frequency and duration, while sensor data from the smart socks were analysed to assess their performance. Results showed that TTB characteristics were consistent with patterns typically associated with repetitive and restrictive behaviours literature, as expected. Both parents and children rated the smart socks as highly comfortable; however, the sensors demonstrated low accuracy, sensitivity, and specificity in the autism group, in contrast to the typically developing children. As expected, TTB were positively correlated with the number of core autism characteristics. No significant correlations were found between tiptoe walking and motor or language skills, although tiptoe running was positively correlated. The study has implications both on the theoretical and clinical levels.